Policies lay down the intent and provide the direction. Viewed within this framework, the recently announced National Health Policy has articulated an ambitious vision of saving lives, promoting wellness and aiming to provide every citizen access good quality health care.
What does it say?
Similar to the National Health Policy 2002, the National Health Policy 2017 has laid down goals that are consistent with the Sustainable Development Goals (SDG). Accordingly, the National Health Policy aims to bring down maternal mortality from the current level of 167 per 100,000 live births to less than 100 by 2020; and under 5 child mortality and infant mortality levels from 49 and 40 per 1000 live births to 23 and 28 by 2025 and 2019 respectively.
Undoubtedly, these are stiff targets to achieve within the timelines indicated for three reasons. Firstly, in health care, as mortality levels drop, reductions become more difficult, challenging and expensive, as those dying require institutional care and a high quality health system consisting of well-trained human resources at the cutting edge, a responsive referral systems and a functioning emergency care that is closely supervised.
Secondly, the geographic and social differentials are very wide within states and districts. For example, there is an over 63 per cent differential under the under 5 child mortality levels between Assam and Kerala and in a state like Madhya Pradesh, Indore has Infant Mortality Rate of 37, three times lesser than Panna. Similarly, coverage levels under immunization, ante natal care or access to health services, safe water, sanitation and nutrition among scheduled tribes and scheduled castes is almost one third lesser than the general population. Bridging these gaps would require significant resources and special strategies.
Thirdly, the National Health Policy has put all its trust and faith in the strategy of public private partnerships through strategic purchasing of services from the private sector. The issue that needs to be addressed is that in those very areas/locations/districts where the poorest live and die, the health system is weak- both public and private.
Massive incentives will need to be given to the providers, whether public or private, to serve in those areas. While so the budgets are restricted. Reconciling such seemingly contradictory ground realities will be the biggest challenge for the government to address if it is serious about achieving the goals laid down.
Clearly, achieving the aim of saving every life would necessitate the building of a strong primary health system. The National Health Policy thankfully does recognize this aspect. An effective primary health care system would however imply working round two operational strategies: one, ensuring close inter-sectoral collaboration; and two, building the public health system to deliver the full complement of preventive, promotive and curative care. Such an assertion is based on the findings of several studies that suggests that social determinants like nutrition, environmental hygiene and education have a direct correlation to maternal and child mortality. For example, the relatively slower decline of maternal mortality in the northern states as compared to the southern states during the period 2005-2014, despite the aggressive implementation of institutional deliveries is indicative of the limitations of a strategy that is not comprehensive and linked with other determinants. Likewise, yet another linkage that the National Health Mission has to ensure is addressing the other causal factors like malaria or TB or diabetes and hypertension that seem to be killing pregnant women and women in their productive age group in larger numbers than on account of mismanaged deliveries.
Secondly, in remote areas that account for three quarters of the maternal and child mortality, data suggests that the private sector provides very poor quality of care and do not have the capacity to discharge preventive and promotive care. This then requires government to invest on building the infrastructure, combining it with a human resource policy that does not depend only on qualified medical doctors. Trained nurse practitioners and doctor assistants are the solution alongside use of technology for instant referrals to qualified doctors and a good transportation network. Merely depending on private sector and hoping they will rise up to discharging their welfare obligation is no solution and is only an abdication of responsibility by the government.
The targets set in the National Health Policy can be achieved, provided there is clarity in the design proposed, clarity in the financial allocations made, and clarity in the incentive structures offered. Since a back of the envelope simple arithmetic of costs and prices shows that the amount the National Health Policy has committed to provide is grossly low, the government will necessarily be making choices – poor or rich, rural-urban, primary care only or secondary and tertiary as well; communicable and a few non communicable disease like TB and malaria or all ailments like kidney transplant and cochlear implant? Prioritization will in such a scenario be inevitable. The concern is that in the absence of delineating such prioritization, programmes that matter to the lives of the very poor may continue to remain underfunded and neglected, giving rise to disparities and inequities. What is needed is a comprehensive approach so that the NHP does not lapse into becoming just yet another document.
– K Sujatha Rao is former Union Secretary of Health and author of the book ‘Do We Care: India’s Health System’.
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